World Allergy Organization

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Application To Host GLORIA

All information received on this form is confidential.

Date of application:

Name of Regional/State/Local Society hosting the conference:

Name of person completing application:

Position within the society:

Address for correspondence:

City:

State/Province:

Postal Code:

Country:

E-mail:

Telephone:

Fax:

Please rank your preference of US GLORIA Module to host at your meeting:

Allergic Conjunctivitis

Allergic Rhinitis

Anaphylaxis

Angioedema

Chronic Rhinosinusitis and Nasal Polyposis

Drug Allergy

Food Allergy

Immunotherapy

Treatment of Severe Asthma

Urticaria

Would you be willing to host 2 GLORIA modules at your meeting?

Yes No

Has your society hosted US GLORIA in the past?

Yes No

Date(s) of meeting:

Site/location:

Objectives/purpose of meeting:

What percentage of your anticipated attendees will fall into the following categories?

a. Allergists

b. General Practitioners

c. Pulmonologists

d. ENT's

e. Dermatologists

f. Nurses

g. Students

h. Other Health Care Professionals

Please specify:

Scientific program topics:

Anticipated attendance number:

Website address for the meeting:

I plan to apply to the ACAAI for Category 1 CME credits:

Yes No

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